Basic Information
| Provider Information | |||||||||
| NPI: | 1063446144 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MBUYAMBA | ||||||||
| FirstName: | MADELEINE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 63 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023014342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085591567 | ||||||||
| FaxNumber: | 5085595073 | ||||||||
| Practice Location | |||||||||
| Address1: | 63 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023014012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085596699 | ||||||||
| FaxNumber: | 5085834649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 05/21/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 159479 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 32530 | 01 | HEALTHY START | OTHER | 98634901 | 01 | MA | NETWORK HEALTH | OTHER | J25606 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 0017976 | 01 | NEIGHBORHOOD HEALTH PLAN | OTHER | 32530 | 01 | CHILDRENS MEDICAL SEC. PL | OTHER | 000000036884 | 01 | MA | BMC HEALTHNET | OTHER |